Oxford Handbook of Midwifery (44 page)

CHAPTER 9
Pregnancy complications

162‌‌

Hyperemesis

Hyperemesis means excessive vomiting and this condition can occur in 3–20% of pregnancies. It is an extremely unpleasant condition and suf- ferers can become depressed and demoralized that the early stage of pregnancy makes them feel so ill.

Hyperemesis gravidarum should be considered when all other causes of persistent nausea and vomiting have been ruled out.

Pyelonephritis, pancreatitis, cholecystitis, hepatitis, appendicitis, gastroenteritis, peptic ulcer disease, thyrotoxicosis, and hyperthyroidism can present in similar fashions, with intractable nausea and vomiting, and are treatable conditions. Late presenters need also to be ruled out for HELLP syndrome and other causes of hepatic and central nervous system dysfunction.

It usually lasts anytime from the sixth to the 16th week of pregnancy and is characterized by:

• Vomiting several times a day
  
• Persistent nausea
  
• Dehydration
  
• Reduced urine output
  
• The appearance of ketones in the urine.
  

  It can be a potentially life-threatening condition especially if the electro- lyte or acid/base balance becomes disordered. In severe cases hospitaliza- tion becomes necessary in order to provide rest.
  

  Intravenous fluid, up to 5–6L/day using the appropriate amounts of sodium, potassium, chloride, lactate or bicarbonate, glucose, and water, are primarily used in correcting the hypovolaemia, electrolyte and acid– base imbalances, and ketosis.
  

  Anti-emetics can be prescribed in the short term, usually promethazine. Fluids and diet are gradually reintroduced until a normal diet is tolerated.
  

  There are usually no ill-effects on the pregnancy and once the condition
  

  improves pregnancy proceeds normally.
  

  Special consideration must be given to the risk of thromboembolism in women with this condition. If hospitalized women require bed rest, the application of thrombo-embolic deterrent stockings (TEDS) is recommended.
  

  Recommended reading
  

  Symonds I (2009). Abnormalities of early pregnancy. In: Fraser D, Cooper M.
  Myles Textbook for Midwives.
  15th edn. London: Churchill Livingstone, pp. 225–6.
  

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  CHAPTER 9
  Pregnancy complications
  

  164‌‌
  

  Infections
  

  Coughs, colds, and flu
  

  These common infections pose little threat to the fetus and symptom relief is all that is necessary. Advise fluids, rest, and paracetamol up to normal maximum doses, e.g. 1g four times a day. Inhaled decongestants are safe but cough linctus should be avoided.
  

  A productive cough could be a sign of bacterial infection requiring antibiotic treatment and the woman should be referred to her GP.
  

  Urinary tract infections
  

  Women should be offered screening by mid-stream urine culture for asymptomatic bacteriuria early in pregnancy, as identification and treat- ment reduce the risk of preterm birth.
  ¹
  

  Around 1 in 25 women develop a urinary tract infection during pregnancy. The symptoms are:
  

• Discomfort or burning sensation on micturition
  
• Pain in the bladder region/lower pelvis
  
• Frequency of micturition.
  

  An ascending infection involving the kidneys or bloodstream may cause:
  

• Loin pain
  
• Vomiting
  
• Fever
  
• Uterine contractions—the symptoms of premature labour may mask a urinary tract infection and midstream urine should be obtained for culture to rule this out.
  

  

  Mild infections are treated with oral antibiotics, but a more serious infec- tion requires admission to hospital for intravenous antibiotic therapy and rest.
  

  Bacterial infections
  

  BV
  is present in up to 20% of pregnant women who are slightly more likely to deliver pre-term.
  ²
  Treatment is with clindamycin orally or vaginally, or metronidazole gel. Reoccurrence is common.
  

  Chlamydia
  affects 2–13% of pregnant women. It is associated with pre- term delivery, pre-labour rupture of the membranes, chorioamnionitis and post-partum endometritis.
  ³
  Chlamydia screening is not offered routinely but this policy may change with the implementation of the opportunistic chlamydia screening programme. Treatment is with erythromycin.
  

  GBS
  is the leading cause of serious neonatal infection in the UK. Approximately 40% of adults carry the bacteria in the gastrointestinal or reproductive tract. Pregnant women are not routinely screened but those who present with high risk factors for this infection are offered screening at 34–36 weeks’ gestation so that intrapartum antibiotics (penicillin) can be administered.
  ⁴
  

  The risk factors are: pre-term delivery, prolonged rupture of the membranes, GBS cultured in a urine sample, known carriage of GBS or a history of GBS in a previous pregnancy.
  

  INFECTIONS
  

  165
  

  Sexually transmitted diseases
  

  Gonorrhea
  is rare but on the increase. It is associated with adverse preg- nancy outcomes;
  ⁵
  however the infection is treatable with penicillin or cip- rofloxacin.
  

  Syphilis
  is an acute or chronic infection screened for in early pregnancy. The incidence in the UK is low and it can be treated with penicillin.
  ⁶
  

  Viral infections
  

  Genital herpes
  

  Presents as a flu-like illness followed by an outbreak of vulval sores which are very painful. These usually heal after 7–10 days. This is sometimes mistaken for candidiasis as it seemingly responds to cream or pessaries. Occasionally it is symptomless.
  

  The herpes virus then remains dormant in the spinal nerves and can be reactivated, causing a secondary attack. During pregnancy herpes causes most problems if a first attack occurs after 28 weeks’ gestation. Secondary attacks are much less of a risk.
  

  The main risk is transmission of the virus to the baby during birth. Herpes can also cause premature labour and affect fetal growth.
  ⁷
  

  An elective caesarean section at 38 weeks’ gestation is usually advised if a primary attack occurs after 28 weeks’ gestation, or in early labour if there are vulval sores present. Affected women may be offered treatment with aciclovir after 20 weeks’ gestation.
  

  Hepatitis B
  

  All women are offered screening in early pregnancy. Hepatitis B during pregnancy does not increase maternal mortality or morbidity or the risk of fetal complications. Approximately 90% of the infants of HBsAg carrier mothers with positive hepatitis B e-antigen (HBeAg) will become carriers
  

  if no immunoprophylaxis is given.
  ⁸
  Neonates given the Hepatitis B immu-
  noglobulin within 24 hours of birth will be prevented from developing the
  

  infection and becoming carriers themselves.
  

  Chickenpox
  

  This is a fairly common infection and many women are exposed during pregnancy.
  

  If a woman has already had chickenpox, there is no risk to the fetus, but if a woman has never had chickenpox and contracts it before 20 weeks’ gestation, there is a risk of the fetus developing a severe infection— chickenpox syndrome.
  ⁹
  

  Varicella zoster immunoglobulin antibody treatment reduces the risk of chickenpox syndrome and should be given 10 days after the initial attack.
  

  Between 20 weeks and term there is no risk to the baby as protective antibodies are produced which cross the placenta.
  

  If a mother develops a rash within a week before delivery to 1 month afterwards, there will not have been time for the transfer of antibodies to take place and the baby is at risk of severe infection after the birth.
  

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  Pregnancy complications
  

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  Toxoplasmosis
  

  Toxoplasmosis is caused by the parasite
  Toxoplasma gondii
  , which is found in raw meat and in cats that eat raw meat and their faeces. It rarely causes illness in an adult, although it can present as a flu-like illness with swollen lymph glands (b see also Food safety, p. 88).
  

  In pregnant women it is of concern as it can lead to fetal infection and the following potential problems: